Grant # ______ (For Foundation Use)
1217 North Sixth Avenue, Suite 3
(515)462-1891
Please submit the original and 16 copies of the four page application (plus any attachments requested, or you deem necessary) to The Foundation. (The application will not be considered unless copies are submitted.)
The application deadline is 4:00 PM, March 25, 2016.
Project Title: ______
Organization Information
Name of organization: ______
Legal name (as listed with IRS) (If different from above):______
Organization Address: ______
Employer Identification Number (EIN): ______
Phone ______Fax ______Website ______
Name of contact person regarding this application: ______
Relation to organization: ______
Phone: ______E-mail: ______
If your organization is not an IRC 501(c)(3) you must have a fiscal sponsor that is either a 501(c)(3) or
170 (c)(1) organization. (Applications submitted without fiscal sponsor will not be considered.) See page 4.
Organization: ______
Total Cost of Project: ______Amount Requested: ______
Overview
Brief Description of Organization: ______
______
Brief Description of Project: ______
______
Type of Request (check one): Capital Based or Program Based
Program Based: Operational, activity, general programmatic support
Capital Based: The building of or physical improvement of something
Project Focus Area (check one):
Arts/Culture/Humanities Human Services Education Environment/Animals
Public/Society Benefit Health Other
Have you received funding from The Foundation previously? _____Yes ____No
If yes, when? ______
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PAGE TWO
The Greater Madison County Community Foundation
Are you requesting for the continuation of a previously funded Foundation project? __Yes __No.
If yes, please indicate reason. ______
______
What is your accounting year? (Mo) to (Mo) _____ to ____.
Describe your organization’s charitable purpose, program activities, and population served:
______
______
List any major changes that have taken place in your organization in the last two years. ______
______
Briefly describe your organization’s local history and major accomplishments.
______
______
______
Request Summary
Describe the proposed project, including the goals and objectives. Discuss the community need for the project, the benefit(s) for the community as a result of the project and the community support for the project and any other information you deem to be significant. (Attach a single sheet if necessary.)
______
______
______
______
______
______
______
Indicate desired impact and how you will measure and evaluate the results of the project. Be specific regarding community needs/issues your project will address.
______
______
______
______
Considering the availability of project funding, describe your timeline for the project including expected start and completion dates.______
______
______
______
Population served (estimated #): ______
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PAGE THREE
Greater Madison County Community Foundation
Project Budget
Expenses
Source Amount
Land Purchase / $Professional Services / $
Construction Costs / $
Equipment Purchase / $
Construction Supplies / $
Training Costs / $
Personnel Costs / $
Other Expense / $
Total:
Income
Source Amount
Sponsor Cash / $Federal Gov. Grants / $
State Gov. Grants / $
Private Foundations / $
Sponsor In-Kind* / $
Private In-Kind* / $
County Foundation / $
Other Income / $
Total:
(Should equal cost of total project.)
*In-kind gift: when a foundation or other entity contributes a good or service in lieu of providing monetary grants. In-kind contributions support the daily operations of an organization.
Approval Agreement from Applicant Organization
We approve submission of this grant request and certify that the purpose of this request is charitable and that any funds received from the Community Foundation will be used solely for the project stated in this application.
Board Chairman or designated representative: ______
(Signature required)
Printed name of Chair, or representative: ______
Date: ______
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Applications are due March 25, 2016
Please deliver to:
Foundation Office
C/O Madison County Development Group
1217 North Sixth Avenue, Suite 3
Winterset, Iowa 50273
Applications will not be accepted electronically.
Thank you!
Questions should be directed to the Foundation Administrator (515) 462-1891 or Foundation President Pat Nelson at 515-468-0775.
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PAGE FOUR
Greater Madison County Community Foundation
If organization applying is not a 501 (c)(3) this form must accompany the grant application.
Fiscal Sponsorship Agreement
Date: ______
Fiscal Sponsor (Legal Applicant): ______
Fiscal Sponsor Contact Person and Email: ______
Fiscal Sponsor Full Mailing Address: ______
Sponsored Organization Conducting Requesting Funding: ______
Project Name: ______
______(hereafter referred to as The Sponsor) has agreed to serve as a fiscal/program sponsor for
the______(hereafter referred to as the Sponsored Org.) as outlined in the attached application
and supporting materials.
The Board of Directors of The Sponsor has passed a resolution adopting the Sponsored Org.’s project as a program or
project consistent with the Sponsor’s purpose and mission. The Sponsored Org.’s financial activities will be accounted
for as a program of The Sponsor for IRS auditing and financial reporting purposes.
Since the Sponsored Org. is not recognized by the IRS as a charitable tax-exempt entity, The Sponsor must exercise
full control over the Sponsored Org.’s financial administration, management and disbursement of funds resulting from
this grant application. The Sponsor has delegated ______(name of person/s) as responsible for
fulfilling of these accounting and reporting functions subject to the ultimate authority of the Board of Directors of The Sponsor.
The Sponsor is responsible for ensuring completion of timely reports and submission of necessary financial statements
to the Community Foundation’s Administrative Office (contact info below). Failure to insure timely reporting on behalf of
the Sponsored Org./Sponsor will also result in a loss of good standing.
This agreement will be in effect from the date of a grant award to support the above-named project until the grant funds are
expended and the final report has been submitted and accepted.
We agree to the terms stated above in this agreement:
Legal Applicant/ Fiscal Sponsor Representative Signature: ______
Printed Name: ______Date: ______
Sponsored Organization Representative Signature: ______
Printed Name: ______Date: ______
*Attach to this agreement the Fiscal Sponsor’s 501(c)(3) Tax-Exempt Determination Letter or comparable proof of charitable exemption. (i.e. a letter from a City, confirming their status as a government entity. Contact our Administrative Office with questions, or for examples of a letter from a City.)*
Definitions/Explanations
Fiscal Sponsor: is an organization that is receiving the money on behalf of the grant applicant and is responsible for disbursing the money for the project and maintaining appropriate documentation. This entity must be a 501(C)(3) or a 170 (c)(1) unit of government in order to serve in this capacity. A fiscal sponsorship agreement must accompany the grant application if a fiscal sponsor is being used. Organizations must be recognized by the Internal Revenue Service as tax-exempt, nonprofit, public charities under section 501(c)(3) or as a “unit of government” under Section 170(c)(1) to receive grant funding. A 501(c)(3) is a section of the Federal Tax Code, which establishes the criteria for tax-exempt charitable organizations. Section170(c)(1) refers to agencies that conduct activities to benefit the public at large, like public schools, state universities, public libraries and volunteer fire departments.